Variation in the use of type and crossmatch blood ordering among patients undergoing hepatic and pancreatic resections

The use of preoperative blood orders involved in major gastrointestinal surgery has been poorly studied. The objective of the current study was to analyze compliance with guidelines and factors associated with crossmatch and blood ordering among patients who underwent a hepatic or pancreatic resection.

All patients who underwent a hepatic or pancreatic resection between 2010 and 2013 at Johns Hopkins Hospital were identified. Crossmatch to transfusion (C/T) ratios were calculated based on transfusion rates and total units used. A C/T ratio of >2.0 was considered excessive.

Among the 2,629 patients, 11,574 units of packed red blood cells (PRBCs) were crossmatched (mean number of PRBC units crossmatched: 5.9 ± 7.3). Of the 2,629 patients, 34.1% of patients received ≥ 1 PRBCs and 3,611 total units of PRBC were transfused, resulting in an institutional C/T ratio of 2.17 based on the proportion of patients transfused and 3.21 based on the overall number of PRBC units transfused. Using our criterion of excessive C/T ratio of >2.0, we found that 411 patients (45.9%) were "excessively" crossmatched among transfused patients. Among nontransfused patients, 41.0% (n = 711) of patients were crossmatched for >2 units PRBC. Factors associated with receipt of "excess" crossmatch included the presence of multiple comorbidities and an estimated blood loss >450 mL (both P < .05). Provider-level variation among surgeons (C/T ratio range 1.22-3.81) also was associated strongly with "excess" crossmatching ratios (odds ratio 2.56, 95% confidence interval 2.09-3.13; P < .001).

More than 1 in 4 patients received crossmatch orders that exceeded institutional and national guidelines. Provider variation both among surgeons and anesthesiologists was an important factor associated with crossmatch variation and excessive ordering of blood for crossmatch in patients undergoing pancreatic and hepatic surgery.